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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation 0 Repair ❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Inspection Date <br />6122/2021 <br />Facility Name <br />Fast N Esy #116 <br />Facility Address <br />1399 E. Yosemite Ave. <br />City <br />Manteca <br />ZIP Code <br />95336 <br />2.: SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Donlee Pump Company <br />Phone <br />(209) 537-9396 <br />Mailing Address <br />2825 Railroad Ave. Ceres CA. 95307 <br />Service Technician Performing Inspection <br />Alex Drambila <br />Contractor/Tank Tester License Number <br />ICC Number <br />8881772 <br />Expiration Date <br />12/23123 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW 162925 <br />2123 <br />Franklin Fueling 2499493702 <br />9119 <br />4.INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />Manufacturer Spec. <br />... ............. <br />5. `CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />I hereby certify that the OPE was inspected in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Se ce Tec nician Signature <br />Date . ,(2 5/z <br />Total # of Nges <br />2 <br />� • Cv <br />CERS = California Environmental Reporting System, ID = Identification, ICC e International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />